Cost-effectiveness of Lifestyle Africa: an adaptation of the diabetes prevention programme for delivery by community health workers in urban South Africa.

BACKGROUND: Lifestyle Africa is an adapted version of the Diabetes Prevention Program designed for delivery by community health workers to socioeconomically disadvantaged populations in low- and middle-income countries (LMICs). Results from the Lifestyle Africa trial conducted in an under-resourced community in South Africa indicated that the programme had a significant effect on reducing haemoglobin A1c (HbA1c). OBJECTIVE: To estimate the cost of implementation and the cost-effectiveness (in cost per point reduction in HbA1c) of the Lifestyle Africa programme to inform decision-makers of the resources required and the value of this intervention. METHODS: Interviews were held with project administrators to identify the activities and resources required to implement the intervention. A direct-measure micro-costing approach was used to determine the number of units and unit cost for each resource. The incremental cost per one point improvement in HbA1c was calculated. RESULTS: The intervention equated to 71 United States dollars (USD) in implementation costs per participant and a 0.26 improvement in HbA1c per participant. CONCLUSIONS: Lifestyle Africa reduced HbA1c for relatively little cost and holds promise for addressing chronic disease in LMIC. Decision-makers should consider the comparative clinical effectiveness and cost-effectiveness of this intervention when making resource allocation decisions. TRIAL REGISTRATION: Trial registration is at ClinicalTrials.gov (NCT03342274).

Scaling Up Improved Inpatient Treatment of Severe Malnutrition: Key Factors and Experiences From South Africa, Bolivia, Malawi, and Ghana.

Severe acute malnutrition (SAM) can have high mortality, especially in very ill children treated in the hospital. Many medical and nursing schools do not adequately, if at all, teach how to manage children with SAM. There is a dearth of experienced practitioners and trainers to serve as exemplars of good practice or participate in capacity development. We consider 4 country studies of scaling up implementation of WHO guidelines for improving the inpatient management of SAM within under-resourced public sector health services in South Africa, Bolivia, Malawi, and Ghana. Drawing on implementation reports, qualitative and quantitative data from our research, prospective and retrospective data collection, self-reflection, and our shared experiences, we review our capacity-building approaches for improving quality of care, implementation effectiveness, and lessons learned. These country studies provide important evidence that improved inpatient management of SAM is scalable in routine health services and scalability is achievable within different contexts and health systems. Effectiveness in reducing inpatient SAM deaths appears to be retained at scale.The country studies show evidence of impact on mortality early in the implementation and scaling-up process. However, it took many years to build workforce capacity, establish monitoring and mentoring procedures, and institutionalize the guidelines within health systems. Key features for success included collaborations to build capacity and undertake operational research and advocacy for guideline adoption; specialist teams to mentor and build confidence and competency through supportive supervision; and political commitment and administrative policies for sustainability. For frontline staff to be confident in their ability to deliver appropriate care competently, an enabling environment and supportive policies and processes are needed at all levels of the health system.

Prevalence of disease complications and risk factor monitoring amongst diabetes and hypertension patients attending chronic disease management programmes in a South African Township.

BACKGROUND: South Africa established chronic disease management programmes (CDMPs) called 'clubs' to ensure quality diabetes care. However, the effectiveness of these clubs remains unclear in terms of disease risk factor monitoring and complication prevention. AIM: We assessed risk factor monitoring, prevalence and determinants of diabetes related complications amongst type-2 diabetes (T2D) and hypertension (HTN) patients attending two CDMPs. SETTING: Urban Township in Cape Town, South Africa. METHODS: Cross-sectional survey combined with a 10-year retrospective medical records analysis of adult T2D/HTN patients attending two CDMPs, using a structured survey questionnaire and an audit tool. Statistical Software for Social Sciences (SPSS) version 25 was used to analyse risk factor monitoring and calculate prevalence of complications. Potential determinants of complications were explored through logistic regression. RESULTS: There were 379 patients in the survey, 372 (97.9%) had HTN whilst 159 (41.9%) had T2D and HTN; 361 medical records were reviewed. Blood pressure (87.7%) and weight (86.6%) were the best monitored risk factors. Foot care (0.0% - 3.9%) and eye screening (0.0% - 1.1%) were least monitored. Nearly 22.0% of patients reported one complication, whilst 9.2% reported ≥ 3 complications. Medically recorded complications ranged from 11.1% (1 complication) to 4.2% with ≥ 3 complications. The most common self-reported and medically recorded complications were eye problems (33%) and peripheral neuropathy (16.4%), respectively. Complication occurrence was positively associated with age and female gender and negatively associated with perceived illness control. CONCLUSIONS: Type-2 diabetes and hypertension patients experienced diabetes related complications and inadequate risk factor monitoring despite attending CDMPs. Increased self-management support is recommended to reduce complication occurrence.

Food purchasing behaviour of shoppers from different South African socio-economic communities: results from grocery receipts, intercept surveys and in-supermarkets audits.

OBJECTIVE: To identify factors associated with food purchasing decisions and expenditure of South African supermarket shoppers across income levels. DESIGN: Intercept surveys were conducted, grocery receipts collated and expenditure coded into categories, with each category calculated as percentage of the total expenditure. In-supermarket food quality audit and shelf space measurements of foods such as fruits and vegetables (F&V) (healthy foods), snacks and sugar-sweetened beverages (SSB) (unhealthy foods) were also assessed. Shoppers and supermarkets were classified by high-, middle- and low-income socio-economic areas (SEA) of residential area and location, respectively. Shoppers were also classified as "out-shoppers" (persons shopping outside their residential SEA) and "in-shoppers" (persons shopping in their residential SEA). Data were analysed using descriptive analysis and ANOVA. SETTING: Supermarkets located in different SEA in urban Cape Town. PARTICIPANTS: Three hundred ninety-five shoppers from eleven purposively selected supermarkets. RESULTS: Shelf space ratio of total healthy foods v. unhealthy foods in all the supermarkets was low, with supermarkets located in high SEA having the lowest ratio but better quality of fresh F&V. The share expenditure on SSB and snacks was higher than F&V in all SEA. Food secure shoppers spent more on food, but food items purchased frequently did not differ from the food insecure shoppers. Socio-economic status and food security were associated with greater expenditure on food items in supermarkets but not with overall healthier food purchases. CONCLUSION: Urban supermarket shoppers in South Africa spent substantially more on unhealthy food items, which were also allocated greater shelf space, compared with healthier foods.

Snapshots of Urban and Rural Food Environments: EPOCH-Based Mapping in a High-, Middle-, and Low-Income Country from a Non-Communicable Disease Perspective.

A changing food environment is implicated as a primary contributor to the increasing levels of non-communicable diseases (NCDs). This study aimed to generate snapshots of selected external food environments to inform intervention strategies for NCD prevention in three countries: Uganda (low income), South Africa (middle income) and Sweden (high income), with one matched pair of urban-rural sites per country. Fifty formal and informal food retail outlets were assessed, and descriptive and comparative statistical analyses were performed. We found that formal food retail outlets in these countries had both positive and negative traits, as they were the main source of basic food items but also made unhealthy food items readily available. The Ugandan setting had predominantly informal outlets, while the Swedish setting had primarily formal outlets and South Africa had both, which fits broadly into the traditional (Uganda), mixed (South Africa) and modern (Sweden) conceptualized food systems. The promotion of unhealthy food products was high in all settings. Uganda had the highest in-community advertising, followed by South Africa and Sweden with the lowest, perhaps related to differences in regulation and implementation. The findings speak to the need to address contextual differences in NCD-related health interventions by incorporating strategies that address the food environment, and for a critical look at regulations that tackle key environment-related factors of food on a larger scale.

Adapting the Diabetes Prevention Program for low- and middle-income countries: preliminary implementation findings from lifestyle Africa.

Rates of cardiovascular disease and diabetes are rising in low- and middle-income countries (LMIC), but there is a dearth of research devoted to developing and evaluating chronic disease interventions in these settings, particularly in Africa. Lifestyle Africa is a novel, culturally adapted version of the Diabetes Prevention Program (DPP) being evaluated in an ongoing community-based cluster-randomized trial in an underresourced urban community in South Africa. The purpose of this study is to describe the adaptations and adaptation process used to develop the program and to report preliminary implementation findings from the first wave of groups (n = 11; 200 individuals) who participated in the intervention. The RE-AIM model and community advisory boards guided the adaptation process. The program was designed to be delivered by community health workers (CHWs) through video-assisted sessions and supplemented with text messages. Participants in the trial were overweight and obese members of existing chronic disease "support groups" served via CHWs. Implementation outcomes included completion of sessions, session attendance, fidelity of session delivery, and participant satisfaction. Results indicated that 10/11 intervention groups completed all 17 core sessions. Average attendance across all sessions and groups was 54% and the percentage who attended at least 75% of sessions across all groups was 35%. Fidelity monitoring indicated a mean of 84% of all required procedures were completed while overall communication skills were rated as "good" to "excellent". These preliminary results support the feasibility of culturally adapting the DPP for delivery by CHWs in underresourced settings in LMIC.

The development of an evidence-based street food vending model within a socioecological framework: A guide for African countries.

In the present global economic crisis and continued rapid urbanization, street food (SF) vending has grown into a practical source of income for people in the developing world. SF are not only appreciated for their unique flavours, convenience, and affordability they also contribute to the economy of the country, the perseverance of cultural and social heritage of society, as well as the potential for maintaining and improving the nutritional status of populations. This study aimed to develop a street food vending model (SFVM) that encompasses healthy and safe food options for consumers including hygiene and safety guidelines and viable business and operations for vendors. An evidence-based approach, i.e. "systematically collected proof", was used to inform the development of this model. Phase 1 included two surveys, one of street food vendors (N = 831) and the other of consumers (N = 1047). These surveys obtained data regarding the vendors' operations and food items they sold and the consumers' purchases and their nutrition knowledge. In Phase 2, interviews and focus groups were conducted with government officials. Additionally, regulations and policies regarding street vending were reviewed to determine available regulations and policies for street food vending. In Phase 3, data from the two phases were integrated and participatory action methods involving street food vendors used to validate the findings and inform the development of a SFVM by engaging in focus group discussions with street food vendors (N = 28). The components of the proposed SFVM comprised four parts, namely a food and nutrition component, a hygiene component, a business component and a vending cart. These components serve as a guide and considers various elements of the socioecological framework, namely intrapersonal/individual and interpersonal factors, the physical environment/community as well as the policy environment. The development of this model can serve as an example to countries which have large street food vending components and wish to optimize their value by making them safe and healthy for consumers. Thus, allowing vendors to trade under optimal conditions giving due consideration to regulations and policy.

Low intake of commonly available fruits and vegetables in socio-economically disadvantaged communities of South Africa: influence of affordability and sugary drinks intake.

BACKGROUND: Consumption of fruits and vegetables reduces the risk of obesity, diabetes, cancer, cardiovascular mortality and all-cause mortality. The study assessed the pattern of intake and the factors that influence daily intake of commonly available fruits and vegetables in economically disadvantaged South African communities. METHODS: This is a cross-sectional study nested on an ongoing longitudinal study in South Africa. Two communities (a rural and urban) of low socio-economic status were purposely selected from two of the nine provinces. A sample of 535 participants aged 30-75 years was randomly selected from the longitudinal cohort of 1220; 411 (78%) women. Data were collected using validated food frequency and structured interviewer-administered questionnaires. Descriptive and multivariate regression analysis were undertaken. RESULTS: A higher proportion of participants in the urban township compared to their rural community counterparts had purchased fruits (93% vs. 51%) and vegetables (62% vs. 56%) either daily or weekly. Only 37.8% of the participants consumed at least two portions of commonly available fruits and vegetables daily, with no differences in the two communities. Daily/weekly purchase of sugar sweetened beverages (SSBs) was associated with daily intake of fruits and vegetables (p = 0.014). Controlling for age and gender, analysis showed that those who spent R1000 (USD71.4) and more on groceries monthly compared to those who spent less, and those who travelled with a personal vehicle to purchase groceries (compared to those who took public transport) were respectively 1.6 times (AOR, 95% CI: 1.05-2.44; p = 0.030) and 2.1 times (AOR, 95% CI: 1.06-4.09; p = 0.003) more likely to consume at least two or more portions of fruits and vegetables daily. Those who purchased SSBs daily or weekly were less likely (AOR, 95% CI: 0.54, 0.36-0.81, p = 0.007) to consume two or more portions of fruits and vegetables daily. The average household monthly income was very low (only 2.6% of households earned R5000 (US$357.1); and education level, attitude towards fruits and vegetables and owning a refrigerator had no significant association with fruits and vegetable daily intake. CONCLUSION: These findings indicate that affordability and frequency of purchase of sugary drinks can influence daily intake of fruits and vegetables in resource-limited communities.

Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes.

This paper reports on the use of reciprocal learning for identifying, adopting and adapting a type 2 diabetes self-management support intervention in a multisite implementation trial conducted in a rural setting in a low-income country (Uganda), a periurban township in a middle-income country (South Africa) and socioeconomically disadvantaged suburbs in a high-income country (Sweden). The learning process was guided by a framework for knowledge translation and structured into three learning cycles, allowing for a balance between evidence, stakeholder interaction and contextual adaptation. Key factors included commitment, common goals, leadership and partnerships. Synergistic outcomes were the cocreation of knowledge, interventions and implementation methods, including reverse innovations such as adaption of community-linked models of care. Contextualisation was achieved by cross-site exchanges and local stakeholder interaction to balance intervention fidelity with local adaptation. Interdisciplinary and cross-site collaboration resulted in the establishment of learning networks. Limitations of reciprocal learning relate to the complexity of the process with unpredictable outcomes and the limited generalisability of results.

Associations of perceived neighbourhood safety from traffic and crime with overweight/obesity among South African adults of low-socioeconomic status.

BACKGROUND: The relationship between perceived neighbourhood safety from traffic and crime with overweight/obesity can provide intervention modalities for obesity, yet no relevant study has been conducted in sub-Saharan African contexts. We investigated the association between perceived neighbourhood safety from traffic and crime with overweight/obesity among urban South African adults. METHODS: This cross-sectional study included 354 adults aged ≥35 years drawn from the Prospective Urban Rural Epidemiology (PURE) cohort study. The Neighborhood Walkability Scale-Africa (NEWS-A) was used to evaluate the perceived neighbourhood safety. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to examine the associations between perceived neighborhood safety and overweight/obesity defined "normal weight" and "overweight/obese" using the 25 Kg/m2 cutoff criterion. RESULTS: In the overall sample, adults who agreed that "the speed of traffic on most nearby roads in their neighborhood was usually slow" were less likely to be overweight/obese (adjusted OR = 0.42; 95%CI 0.23-0.76). Those who agreed that "there was too much crime in their neighborhood to go outside for walks or play during the day" were more likely to be overweight/obese (OR = 2.41; 1.09-5.29). These associations were driven by significant associations in women, and no association in men, with significant statistical interactions. CONCLUSION: Perceived neighborhood safety from traffic and crime was associated with overweight/obesity among South African adults. Our findings provide preliminary evidence on the need to secure safer environments for walkability. Future work should also consider perceptions of the neighbourhood related to food choice.

Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals.

BACKGROUND: Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas. OBJECTIVE: To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa. METHODS: An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis. FINDINGS: Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians. CONCLUSION: Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings.

Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study.

BACKGROUND: There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development. METHODS: We assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from -1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated. FINDINGS: The proportion of patients with cardiovascular disease on three medications ranged from 0% in South Africa (95% CI 0-1·7), Tanzania (0-3·6), and Zimbabwe (0-5·1), to 49·3% in Canada (44·4-54·3). Proportions receiving at least one drug varied from 2·0% (95% CI 0·5-6·9) in Tanzania to 91·4% (86·6-94·6) in Sweden. There was significant (p<0·05) pro-rich inequality in Saudi Arabia, China, Colombia, India, Pakistan, and Zimbabwe. Pro-poor distributions were observed in Sweden, Brazil, Chile, Poland, and the occupied Palestinian territory. The strongest predictors of inequality were public expenditure on health and overall use of secondary prevention medicines. INTERPRETATION: Use of medication for secondary prevention of cardiovascular disease is alarmingly low. In many countries with the lowest use, pro-rich inequality is greatest. Policies associated with an equal or pro-poor distribution include free medications and community health programmes to support adherence to medications. FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).

Reducing the Role of the Food, Tobacco, and Alcohol Industries in Noncommunicable Disease Risk in South Africa.

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs.

Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data.

BACKGROUND: WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. METHODS: We analysed information about availability and costs of cardiovascular disease medicines (aspirin, ß blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. FINDINGS: Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). INTERPRETATION: Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Healthcare Professional Shortage and Task-Shifting to Prevent Cardiovascular Disease: Implications for Low- and Middle-Income Countries.

Cardiovascular diseases (CVD) account for 18 million of annual global deaths with more than three quarters of these deaths occurring in low- and middle-income countries (LMIC). In LMIC, the distribution of risk factors is heterogeneous, with urban areas being the worst affected. Despite the availability of effective CVD interventions in developed countries, many poor countries still struggle to provide care due to lack of resources. In addition, many LMIC suffer from staff shortages which pose additional burden to the healthcare system. Regardless of these challenges, there are potentially effective strategies such as task-shifting which have been used for chronic conditions such as HIV to address the human resource crisis. We propose that through task-shifting, certain tasks related to prevention be shifted to non-physician health workers as well as non-nurse health workers such as community health workers. Such steps will allow better coverage of segments of the underserved population. We recognise that for task-shifting to be effective, issues such as clearly defined roles, evaluation, on-going training, and supervision must be addressed.

Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries.

In low-resource settings, a physician is not always available. We recently demonstrated that community health workers-instead of physicians or nurses-can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone-based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.

An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study.

BACKGROUND: Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study we investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. METHODS: This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community's predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35-74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The primary endpoint of this study was the level of direct agreement between risk scores assigned by the community health workers and the health professionals. FINDINGS: Of 68 community health worker trainees recruited between June 4, 2012, and Feb 8, 2013, 42 were deemed qualified to do fieldwork (15 in Bangladesh, eight in Guatemala, nine in Mexico, and ten in South Africa). Across all sites, 4383 community members were approached for participation and 4049 completed screening. The mean level of agreement between the two sets of risk scores was 96·8% (weighted κ=0·948, 95% CI 0·936-0·961) and community health workers showed that 263 (6%) of 4049 people had a 5-year cardiovascular disease risk of greater than 20%. INTERPRETATION: Health workers without formal professional training can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease. Using community health workers for this screening would free up trained health professionals in low-resource settings to do tasks that need high levels of formal, professional training.

Socio-cultural, environmental and behavioural determinants of obesity in black South African women.

South Africa (SA) is undergoing a rapid epidemiological transition and has the highest prevalence of obesity in sub-Saharan Africa (SSA), with black women being the most affected (obesity prevalence 31.8%). Although genetic factors are important, socio-cultural, environmental and behavioural factors, as well as the influence of socio-economic status, more likely explain the high prevalence of obesity in black SA women. This review examines these determinants in black SA women, and compares them to their white counterparts, black SA men, and where appropriate, to women from SSA. Specifically this review focuses on environmental factors influencing obesity, the influence of urbanisation, as well as the interaction with socio-cultural and socio-economic factors. In addition, the role of maternal and early life factors and cultural aspects relating to body image are discussed. This information can be used to guide public health interventions aimed at reducing obesity in black SA women.

Perceptions about body image and sizes among Black African girls living in Cape Town.

OBJECTIVE: To assess beliefs about body size (fatness and thinness) and body image in Black girls aged 10-18 years living in Cape Town. DESIGN: Exploratory using qualitative methods. SETTING: Cape Town, South Africa. METHOD: Participants were Black African girls (n=240), aged 10-18 years, who attended 5 primary and 6 high schools in Black townships in Cape Town. The schools and the girls were randomly selected. This paper presents qualitative data from 6 focus groups among 60 girls regarding their beliefs about thinness and fatness, and the advantages and disadvantages of being overweight or thin. RESULTS: Beliefs regarding body image indicate that two thirds of the girls perceived fatness as a sign of happiness and wealth. Socially, fatness was accepted but one third of the girls had contradictory views about its advantages. Among obese girls who believed that being obese was preferable, the dominant reasons were that being fat allowed one to engage in sport activities that need strength and also makes one look respectable. On the other hand fatness was viewed as associated with diseases such as diabetes and hypertension and with increased difficulty in finding appropriate clothing sizes. Three quarters of the girls associated thinness with ill health particularly HIV and AIDS and tuberculosis. An advantage of thinness was being less prone to develop chronic non-communicable diseases. CONCLUSION: The study shows that opinions and beliefs about body image start in adolescence. It is therefore important to consider these perceptions when designing interventions for preventing obesity and other chronic non-communicable diseases during early childhood.